Place, i.e., Shop No./House No. where it is to be imported together with the name of village/town, taluka and district.
Name and address of the person to whom the spirituous preparation is to be exported.
Importing place (name of the village/town, taluka, district and State).
Route by which to be exported (please state railway route and also the road route, if any).
Whether the application for export of the spirituous preparation is accompanied by a corresponding import permit or no objection certificate granted by the Collector or Excise Officer of the district to which it is to be exported.
Whether the applicant has exported this preparation in past one year.
Whether the applicant holds a licence under
- The Drugs Act, 1940;
- The Bombay Spirituous Medicinal Preparation (Sale) Rules 1954;
- The Bombay Toilet Preparations (Sale) Rules 1954;
- The Spirituous Preparations (Inter-State Trade and Commerce) Control Act, 1955;
- The Bombay Drugs (Control) Act, 1959.
I have not been convicted on (date)1
I have not been convicted at any time of an offence punishable under any provision of the Bombay Prohibition Act, 1949, the Bombay Drugs (Control) Act, 1959, the Spirituous Preparations (Inter-State Trade and Commerce) Control Act, 1955, the Dangerous Drugs Act, 1930 or the Drugs Act, 1940, or any other law relating to liquor, intoxicating drugs or opium.
I declare that the above particulars are correct.
I undertake that as soon as possible within three months of the expiry of the pass for the export of the abovementioned spirituous preparation, I shall produce before the local Superintendent of Prohibition and Excise or District Inspector of Prohibition and Excise, as the case may be, a receipt signed by the importer in token of his having received the spirituous preparation in question.